6.6 Discharge planning
The goal of discharge planning is two-fold
- to prevent common problems, and
- to enhance maternal self-esteem and self-confidence1
It is the duty of care of the health professionals caring for the mother-baby dyad to ensure that all mothers, particularly those who have not had prenatal education, know how to recognise wellness in their baby and adequate transfer of milk and to react quickly when anything abnormal occurs.
Preventing common problems
Timing of follow-up
Routine follow-up with a qualified health care provider must be confirmed with the parents prior to discharge. A Clinical Practice Guideline recommends the following appointment schedule (AAP Subcommittee on Hyperbilirubinemia, 2004).
Age of infant at discharge | Should be seen by |
---|---|
Before 24hr old | 72 hrs (3 days) |
From 24 - <48 hrs | 96 hrs (4 days) |
From 48 - 72 hrs | 120 hrs (5 days) |
For some newborns discharged before 48 hours, 2 follow-up visits may be required, the first visit between 24 and 72 hours and the second between 72 and 120 hours. |
Critical warning signs
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![]() | ![]() The 3 Red Flags!Optimal birth circumstances and good post natal breastfeeding care will significantly reduce the incidence of infant problems. Each of these signs is an indicator that there may be a breastfeeding problem or something more serious.Any of these signs need immediate medical attention. | ![]() |
#1. Baby's output is less than expected.
Review the table 6.2 Breastfeeding Messages
Do all mothers have a copy of that table to take home? .
Output is a direct indicator of intake - ensure that you can accurately describe normal urine and stool output of the breastfed infant. Ask about the pinkish/rusty stain on a nappy/diaper which is urates in urine. This is normal until baby is 72 hours old (3 completed days). Secretion of urates in urine is a direct function of the serum uric acid concentration (ie blood levels). It is normal to see urates on a nappy/diaper with a scant volume of urine until Day 4. As the milk intake increases on Day 4 urates should no longer be seen.
A note of caution to health professionals who provide only telephone consultations ... your image of a wet nappy/diaper, or a reasonable bowel action may not match the mother's impression. Urine should be clear and each nappy/diaper heavy. Although not a pleasant image, it is helpful to describe a 'handful' size as being a good volume of stooling. This is a very clear picture and will help the mother understand that scant frequent stainings are inadequate.
If there is any doubt at all you must organize for the baby to have medical review urgently.
#2. Breastfeeding is painful.
Breastfeeding should not be painful.
Pain during feeding, misshapen or damaged nipples or pain continuing after the feeding are all indicators that baby is poorly latched and milk transfer will be compromised. A hot or inflamed painful breast is a sign of severe engorgement, or mastitis with reduced milk transfer as a result. Painful breastfeeding is abnormal!
Immediately seek help from an expert in breastfeeding.
#3. Increasing jaundice
Jaundice is a physiological state and is an expected developmental state for the majority of breastfed babies. Jaundice peaks at about Day 3 then gradually fades over the next few weeks. Jaundice should not be seen below the level of the umbilicus.
However, increasing jaundice causes sleepiness and poor feeding; conversely, poor feeding causes increased jaundice.
Teach parents to check for jaundice by observing their baby in natural daylight and putting finger pressure on their baby's forehead, upper chest, arms, abdomen, upper legs and watching for blanching.
Instruct parents that jaundice below the umbilicus is to be reported immediately to their baby's health professional.
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![]() | ![]() Return for immediate assessment
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![]() | ![]() Workbook Activity 6.6Complete Activity 6.6 in your workbook. | ![]() |
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![]() | ![]() These symptoms are the most important for the parents to remember and seek help with if they develop. Succinct instructions will more likely be remembered by parents. Ensure they know to seek urgent review by their health care provider whenever any of those points are abnormal. | ![]() |
Contraception
Preventing an unwanted pregnancy is important to women, and adequate child-spacing is important to the mother's health and the health of the new baby. Breastfeeding is also of paramount importance to the health of both mother and baby.
It is preferable for the mother to recover her nutritional status following the demands of pregnancy and lactation. Recovery of these stores prior to a subsequent pregnancy is important for her health - a recuperative period of less than 6 months between the end of breastfeeding and the next pregnancy is associated with depletion of maternal nutrient stores.2
Mothers therefore require counselling on selection of a contraceptive method that is
- highly effective in preventing pregnancy, and
- does not interfere with breastfeeding.
The Lactational Amenorrhea Method (LAM) of contraception has been extensively studied and found to be more effective than the progestin-only contraceptive pill. Additionally all forms of hormonal contraceptive have the potential to adversely affect breastfeeding.
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![]() | ![]() Contraception for breastfeeding mothersTo read more about other contraceptive methods during lactation click on the icon on the left, print the page and file it with your course notes. From this page you'll find further links and references. | ![]() |

Using the Lactational Amenorrhea Method of contraception.
Graphic © Health e-Learning
The quality of contraceptive/fertility counselling given to a woman significantly influences its effectiveness. When giving advice about any contraception ensure you understand it completely.
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![]() | ![]() Workbook Activity 6.7Complete Activity 6.7 in your workbook. | ![]() |
Consolidating learning
Practical skills should be reinforced by educational materials which must be
- accurate,
- consistent within themselves and with previous verbal teaching,
- written at an appropriate reading-age, and
- free from commercial advertising.
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![]() | ![]() Resource materials for mothersForm a group to look at ALL the materials that are given to mothers. Each one should be discussed and explained to the mother as it is given. Are all the materials necessary? Are all staff familiar with the materials? "The critical warning signs" handout is the most important - does it stand out from the brochures? Perhaps you could start a working group to design/update this vital parent information page? | ![]() |
Discharge packs DO influence actions, particularly in regard to breastfeeding. Artificial formula company sponsored packs reduce the likelihood of exclusive breastfeeding3 and therefore for the health and safety of mother and baby they should not be distributed by any health care facilities.
Referral to mother-to-mother support network
Baby Friendly Step 10 and Point 7
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Step 10 of the Ten Steps to Successful Breastfeeding, and Point 7 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
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Attendance at mother-to-mother support groups or follow-up by peer counselors has demonstrated significant increases in maintaining exclusive breastfeeding. 4 Strategies that depend mainly on face-to-face support appear more effective than those that rely primarily on telephone contact. 5 Parents should be given information about the location and availability of these services with encouragement to use the services.
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![]() | ![]() How is the information provided?Does your Unit have a list of all the available breastfeeding support groups and networks in your area? Is it up-to-date with current phone numbers and meeting places and dates? Are representatives from these groups welcome to meet with mothers in your Unit?
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© Australian Breastfeeding Association
What should I remember?
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Self-test Quiz
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Assessment Quiz
When you are happy that you've understood all the information in this topic you will be ready to complete the Module 6 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 6.
Notes
- # Friedman MA et al. (2004) Discharge criteria for the term newborn.
- # Merchant K et al. (1990) Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals.
- # Donnelly A et al. (2004) Commercial hospital discharge packs for breastfeeding women
- # Hoddinott P et al. (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland
- # Sikorski J et al. (2004) Support for breastfeeding mothers